Clinical Management Research Articles

Drug reaction with eosinophilia and systemic symptoms: Analysis of cutaneous phenotype as a prognosis factor

Study objectiveThe DRESS syndrome (drug reaction with eosinophilia and systemic symptoms) is a severe and potentially fatal toxidermia due to various visceral involvements. Identifying factors predisposing to serious complications is essential for clinical and therapeutic management. This study aims to analyze the cutaneous presentation of DRESS and its role as a prognostic factor. Patients and methodsThis is a retrospective, descriptive, and analytical study conducted over nine years at the dermatology department in Fes, including all hospitalized DRESS cases. ResultsThe maculopapular rash was the most frequent phenotype (49.3%), followed by erythroderma, morbilliform exanthem, and polymorphous erythema-like rash. In all, 52.8% of patients had renal involvement and 45.8% had hepatic involvement, while 81.9% exhibited hypereosinophilia. The maculopapular rash and erythroderma were more associated with internal organ involvement, although no significant statistical correlation could be demonstrated. Allopurinol was the most implicated drug in 51.4% of the cases. No correlation was found between the type of medication and the cutaneous presentation. In all, 8.3% of the patients died, primarily those with erythroderma (15.8%). ConclusionOur study demonstrated that maculopapular rash and erythroderma are the most common presentations and are most associated with internal organ complications, with a more unfavorable prognosis for erythrodermic cases.

Clinical profile, demographic distribution, and management of Posner-Schlossman syndrome.

Clinical profile, demographic distribution, and management of Posner-Schlossman syndrome.

Response comment on "Clinical profile, demographic distribution, and management of Posner-Schlossman syndrome: An electronic medical record-driven data analytics from an eye care network in India".

Response comment on "Clinical profile, demographic distribution, and management of Posner-Schlossman syndrome: An electronic medical record-driven data analytics from an eye care network in India".

Pseudo-Worsening of Kidney Function Due to Inhibition of Renal Creatinine Secretion: Quality of Information Provided in Prescribing Information/SmPC.

Determination of serum creatinine concentrations and subsequent calculation of estimated glomerular filtration rates (eGFR) is a cornerstone of clinical medicine. Crucial clinical decisions such as drug treatment discontinuations are based on eGFR calculated from serum creatinine measurements. However, creatinine is not only filtered in the kidneys, but also actively secreted into urine. Creatinine transporters such as OCT2, OCT3, MATE1, MATE2-K, and OAT2 expressed in proximal tubular cells are responsible for active renal secretion of creatinine. Multiple drugs (e.g., oral antitumor drugs) inhibit these transporters thereby causing a pseudo-worsening of kidney function with an increase in serum creatinine concentrations and a decrease in eGFR while other methods for eGFR determination (e.g., by cystatin C) reveal normal kidney function. Since US Prescribing Information (PI) and European Summaries of Product Characteristics (SmPCs) are the most relevant source of information for physicians, we investigated the quality of information in US PI/German SmPCs of drugs with clear evidence for pseudo-worsening of kidney function. 514 drugs putatively interacting with creatinine transporters were identified. For 149 of those drugs, an increase in serum creatinine concentrations has been described. Available data confirmed the existence of pseudo-worsening of kidney function for 30 of those drugs, for the remaining 119 drugs existing data are insufficient. Only 23.5% (12/51) of the 30 drugs' PI/SmPCs contained unambiguous statements on this proven pseudo-worsening of kidney function and gave clear recommendations for clinical management. Taken together, inadequate information provided in PI or SmPCs on the pseudo-worsening of kidney function poses patients at unnecessary risks.

Clinical management of mandibular permanent premolars with periapical lesion and bilateral supernumerary teeth: A 7-years follow-up case report

Objectifs: This 7-years follow-up case report describes two diversified strategies for the management of bilateral mandibular permanent premolars associated with periapical lesion and unerupted supernumerary teeth. Case Report: A non-syndromic 9 years-old Asian female patient presented pain and swelling of the 35 in anatomical contiguity with an immature and unerupted supernumerary tooth. Clinical examination revealed an intraoral vestibular sinus tract related to the necrotic 35. Periapical radiography and CBCT showed that the 35 had an immature apex associated with a periapical lesion, and a supernumerary tooth in a lingual direction. Endodontic treatment of the 35 was performed by creating an apical plug with ProRoot MTA, while the supernumerary tooth was monitored radiographically with no intervention. Four years later, the 45 developed the same clinical condition of the left arch. Radiographic examination revealed a periapical lesion with massive periapical bone resorption, and a supernumerary tooth in normal alignment. The second premolar was herein extracted to allow for eruption of the supernumerary tooth. Outcomes: 3-years follow-up revealed continued root maturation and its spontaneous eruption in the dental arch. Proper healing of both mandibular lesions was monitored after 10 months, 3-years and 7-years revealing no recurrence on both sides.

Investigating High-risk Factors, Precise Diagnosis, and Treatment of Castration- Resistant Prostate Cancer (CRPC).

The treatment of metastatic castration-resistant prostate cancer (mCRPC) in the actual world currently presents difficulties. In light of this, it is crucial to investigate high-risk factors for the progression of advanced prostate cancer and to identify methods for delaying the onset of CRPC. This study aimed to explore the high-risk factors that impact the progression of prostate cancer and emphasize the significance of precise diagnosis and treatment based on etiological classification in the clinical management of castration-resistant prostate cancer. A retrospective analysis was conducted on 277 newly diagnosed cases of PCa treated with endocrine therapy. A follow-up was done on prostate-specific antigen (PSA) levels and testosterone. Additionally, a prospective analysis was performed on the clinical data of 60 patients with CRPC. Following the principle of "4W1H", 30 patients were included in the precision treatment group for a second biopsy and related tests, while another 30 patients were included in the conventional treatment group. The therapeutic effect and prognosis of the two groups were observed. Distant metastasis (HR = 1.879, 95% CI: 1.311 ~ 2.694, P = 0.001), PSA nadir > 0.2 ng/mL (HR = 1.843, 95% CI: 1.338 ~ 2.540, P = 0.001), testosterone nadir > 20 ng/dL (HR = 1.403, 95% CI: 1.035 ~ 1.904, P = 0.029), and time to testosterone nadir > 6 months (HR = 1.919, 95% CI: 1.364 ~ 2.701, P = 0.001) were risk factors for the progression to CRPC. Patients in the CRPC group were treated with precision therapy and conventional therapy based on their molecular subtyping. The precision treatment group showed a significantly prolonged median PSA progression-free survival compared to the conventional treatment group (16.0 months vs. 13.0 months, P=0.025). The median radiographic progression-free survival was also significantly extended in the precision treatment group compared to the conventional treatment group (21.0 months vs. 16.0 months, P=0.042). Patients with prostate cancer diagnosed with distant metastasis at initial presentation require early intervention. Close monitoring of PSA and serum testosterone changes is necessary during the process of endocrine therapy. After entering the CRPC stage, the etiological classification precision treatment can improve the therapeutic effect and improve the prognosis of patients.

Cytological diagnosis of follicular dendritic cell sarcoma with a unique pattern of D2-40 immunoexpression.

Fine needle aspiration procedure is routinely used for cytological diagnosis of nodal or extra nodal lesions. Follicular dendritic cell sarcoma (FDCS) is a rare mesenchymal neoplasm arising from follicular dendritic cells of lymphoid follicles at nodal and extranodal sites. Multimodal therapies have emerged for FDCS, necessitating its accurate pathologic diagnosis with additional ancillary testing for directing clinical management. By immunohistochemical analysis, FDCS is positive for the complement receptors CD21, CD23, and CD35. In addition, D2-40 is reported to be highly sensitive for FDCS with a strong membranous pattern of expression. In this study, we present the cytological diagnosis of a case of FDCS in retroperitoneal lymph nodes with an emphasis on a unique staining pattern of D2-40 which showed a strong nuclear pattern in tumor cells comparable to the membranous pattern of D2-40 on the control tissue and other surgical cases of FDCS in our comparative study.

The intersection of clinical trial management and patient advocacy: How research professionals can promote patient rights while upholding clinical excellence

The purpose of this study was to investigate the intersection of clinical trial management and patient advocacy, focusing on how research professionals can promote patient rights while upholding clinical excellence. As clinical trials evolve to become more patient-centered, balancing ethical obligations with scientific rigor remains a significant challenge. This paper explores key concepts such as informed consent, patient engagement, data privacy, and the ethical responsibilities of research professionals. Additionally, it examines the role of emerging technologies, including mobile health applications, wearable devices, telemedicine, and blockchain, in enhancing patient advocacy and improving trial outcomes. A thorough literature review and analysis were conducted to identify the challenges faced in integrating patient advocacy into clinical trial management. The study also highlights the critical role of research professionals in ensuring that patient rights are respected while addressing the complexities of global clinical trials, where varying ethical standards pose additional challenges. The findings suggest that patient-centric approaches, supported by digital tools, can significantly improve the ethical integrity of clinical trials, ensuring greater inclusivity, accessibility, and retention of participants. However, these innovations also raise concerns regarding data security, necessitating the implementation of robust cybersecurity measures to protect patient confidentiality. In conclusion, the study recommends the adoption of decentralized clinical trials and the harmonization of global regulatory frameworks to ensure consistent ethical standards. Research professionals must prioritize patient welfare while embracing technological advancements that offer opportunities for more efficient and inclusive clinical research. By striking this balance, clinical trials can better serve both scientific progress and the ethical imperatives of patient advocacy.

The role of electronic data capture systems in clinical trials: Streamlining data integrity and improving compliance with FDA and ICH/GCP guidelines

This study investigates the transformative role of Electronic Data Capture (EDC) systems in clinical trials, emphasizing their impact on data integrity, compliance with regulatory standards, and the efficiency of trial processes. The purpose of the research was to critically analyze how EDC systems align with FDA and ICH/GCP guidelines, addressing the complexities of modern clinical trials. By conducting a detailed literature review, the study explores the benefits, challenges, and technological advancements associated with EDC systems. Key findings highlight the significant advantages of EDC systems in enhancing data accuracy, real-time monitoring, and facilitating regulatory compliance through secure data management and audit trails. The study also identifies several challenges, including high implementation costs, data privacy concerns, and integration issues with other digital trial technologies. Technological advancements, such as artificial intelligence, blockchain, and decentralized trial models, are explored as promising solutions to these limitations, offering new avenues for optimizing clinical trial management. The study concludes that EDC systems have revolutionized clinical trials, streamlining data collection and analysis while ensuring compliance with stringent regulatory requirements. It recommends continued investment in EDC technologies, enhanced training for trial staff, and the integration of cutting-edge innovations to ensure future clinical trials' success.

Histopathological patterns of gastrointestinal lesions: Insights from a Tertiary Care Centre

Gastrointestinal (GI) lesions are a common clinical concern with significant implications for patient health, particularly in cases involving malignancies. Understanding the histopathological spectrum of these lesions is crucial for improving diagnosis and treatment strategies. This study aimed to investigate the histopathological spectrum of gastrointestinal lesions at a tertiary care center, focusing on the prevalence of different types of lesions and their distribution according to clinicopathological parameters. Methods: This cross-sectional study was conducted over a one-year period, from November 2022, to October 2023, at the Department of Pathology, Rohilkhand Medical College and Hospital, Bareilly, UP. A total of 100 patients with clinically suspected GI lesions were included. Biopsy specimens were collected and analyzed using standard histopathological techniques. The data were analyzed to determine the frequency of different types of GI lesions and their correlation with clinical features. Results: The study found that inflammatory lesions were the most prevalent, accounting for 57% of the cases. Malignant lesions were identified in 35% of the patients, with adenocarcinoma being the most common malignancy, especially in the colon, representing 57.14% of malignant cases. The small intestine was the most frequently affected anatomical site, involved in 33% of the cases, followed by the appendix at 22%. The majority of patients were middle-aged males, with a significant correlation between the type of lesion and gender. Conclusion: This study highlights the significant burden of gastrointestinal lesions, particularly inflammatory and malignant lesions, in the studied population. The findings underscore the importance of early detection and intervention to prevent the progression of these lesions, particularly in high-risk groups such as older males. Enhanced clinical management strategies are needed to address the substantial impact of GI pathologies on patient health.

Clinical management model for impulse control disorders in Parkinson's disease.

Over the last decade, we have gained a better understanding of impulse control disorder in Parkinson's disease (PD-ICD), a medication complication in PD. Researchers were aware of its complexity and took efforts to learn more about its diagnostic and treatment possibilities. Nevertheless, clinical management for it is currently neglected. We conducted a narrative overview of literature published from 2012 to October 2023 on various aspects of clinical management for PD-ICD. A potential "susceptibility-catalytic-stress" model in the development of PD-ICD was proposed and a profile encoding predictors for PD-ICD was created. Based on these predictors, some methods for prediction were recently developed for better prediction, such as the polymorphic dopamine genetic risk score and the clinic-genetic ICD-risk score. A variety of treatment options, including dose reduction of dopamine receptor agonists (DAs), DAs removal, DAs switch, and add-on therapy, are investigated with inconsistent reports. Based on current findings, we developed a clinical management model prototype centered on prevention, consisting of prediction, prevention, follow-up and monitoring, therapy, and recurrence prevention, for clinical reference, and further proposed 4 key clinical management principles, including standardization, prediction centered, persistence, and whole course.

Retrospective Evaluation of Clinical Characteristics of Children with Cat Sensitivity

Aims: Cat allergy has an important place among allergic diseases and it is known that environmental factors as well as genetic factors affect sensitisation. It has been reported that having a cat at home increases the risk of sensitisation, especially in susceptible individuals. The aim of this study was to retrospectively evaluate the clinical features of cat sensitisation in children. Methods: In this descriptive retrospective study, children aged 0-18 years with cat sensitisation who were admitted to the clinic between June 2023 and December 2023 were examined. Clinical characteristics, total IgE, eosinophil count, specific IgE values and skin prick test results were retrospectively evaluated using data obtained from the hospital database. Results: The study included 76 children with cat sensitisation. The mean age was 7 years and 56.6% were male. The most common diagnoses were asthma (63.2%) and allergic rhinitis (31.6%). Cat sensitisation was positive in 100% of the patients, house dust mite sensitisation was found in 78.9% and pollen sensitisation in 14.5%. Total IgE levels of patients with multiple allergies were significantly higher than those without multiple allergies. Conclusion: The study showed that additional allergen sensitisation was common in children with cat sensitisation and the most common diagnoses were allergic rhinitis and asthma. The findings are consistent with the existing literature and emphasise the importance of total IgE in the clinical management of allergic diseases.

Local Delivery of Exosomes and Antibiotics in Hydroxyapatite-Based Nanocement for Osteomyelitis Management.

The management of bone and joint infections is a formidable challenge in orthopedics and poses a global health concern. While clinical management emphasizes infection prevention and complete eradication, an effective strategy for stabilizing skeletal tissue with adequate soft tissue coverage remains limited. In this study, we have employed a novel approach of using the local delivery of exosomes and antibiotics (rifampicin) using a hydroxyapatite-based nanocement carrier to manage the residual space created during debridement effectively. Additionally, we synthesized a periosteum-guiding antioxidant herbal membrane to leverage the inherent periosteum regeneration capability of the bone, facilitating bone callus repair and natural healing. The synthesized scaffolds were biocompatible and demonstrated potent antibacterial activity in vitro. When evaluated in vivo in the Staphylococcus aureus-induced rat tibial osteomyelitis model, the released drugs successfully cleared the residual bacteria and the released exosome promoted bone healing, resulting in 3-fold increase in bone volume as analyzed via micro-CT analysis. Immunofluorescence staining of periosteum-specific markers also indicated the complete formation of periosteal layers, thus highlighting the complete bone repair.

Paracetamol and ibuprofen fixed-dose combination for the management of acute mild-to-moderate pain in children: strengthening and enhancing of result of Nominal Group Technique through Delphi consensus

BackgroundParacetamol and ibuprofen are the most commonly used drugs for pain treatment in children and their combination has shown improved analgesic effect compared to treatment with either drug alone. Current literature lacks specific guidelines regarding the settings in which this combination should be adopted.MethodsThe survey, conducted with Delphi methodology, involved 75 hospital and outpatient pediatricians with clinical experience in the management of pain in children. Pediatricians involved were asked to validate or not the results of the previous NominalGroup Tecnique (NGT) consensus and thus specify the optimal clinical settings in which the paracetamol/ibuprofen fixed-dose combination could be adopted.ResultsThe results confirm the importance of the fixed-dose paracetamol and ibuprofen combination for the control of mild-to-moderate acute pain in children. Particularly, this association seems to be appropriate in case of headache, earache, odontalgia and musculoskeletal pain, and in specific settings such as post-operative and post-procedural pain. The broadening of the panel brought to slight variations in clinical management practices between hospital and outpatient specialists. Nonetheless, overall consensus supports the notion that the fixed dose combination is more efficacious than monotherapies and it is well tolerated. Moreover, experts unanimously agree on the usefulness of the combination for caregivers, leading to improved adherence and effectiveness.ConclusionsBoth the NGT consensus and the broader Delphi consensus confirm the usefulness of the paracetamol-ibuprofen fixed-dose combination in pediatric pain. This is attributed to its superior effectiveness compared to monotherapies, a good tolerability profile, and improved compliance and ease of use. Some pain settings related to chronic, inflammatory and rheumatological pathologies remain to be investigated to evaluate the use of this combination.

Clinical management and outcomes of patients with infective endocarditis according to frailty status

Abstract Background infective endocarditis (IE) remains a severe condition associated with a remarkably high mortality in certain groups of patients Purpose the aim of this study was to compare both the clinical management and short and mid-term prognosis of patients with IE according to their frailty status. Methods: a total of 200 cases of confirmed IE were consecutively collected in two tertiary hospitals between September 2016 and February 2021, and prospectively followed during one year after diagnosis. Patients were categorised according to the 5-item FRAIL scale as: Group A (n=48), for scores >2, and Group B (n=152), for scores <=2. Results mean age was 70 [SD 15] years, 64% were men and community-acquired infections were 69%. Baseline and clinical data are shown in Table 1. Enterococci were more frequent in Group A, but no significant differences were found regarding infection site, presence of vegetations or periannular complications, time to diagnosis or length of stay. During hospitalization, acute heart failure, delirium and bronchoaspiration were more common among frail patients. Unlike 18F-FDG PET/CT, which was more frequently done in Group B (34 vs 17%, p 0.03), transesophageal echocardiography was similarly performed between groups (92 vs 97%, p 0.08). Less frail patients underwent cardiac surgery (42 vs 68%, p 0.001), with a larger proportion of inoperable patients despite meeting surgical criteria (29 vs 12%, p 0.002). In-hospital mortality was higher in Group A, both overall and by therapeutic strategies, except in those inoperable patients with surgical indication but treated conservatively, where mortality did not differ between groups. Among survivors who completed follow-up (n=144), although recurrence rates were similar, readmission (75 vs 35%, p <0.001) and all-cause mortality rates (36 vs 5%, p <0.001) in Group A exceeded those from Group B. Predictors of in-hospital and 1-year mortality were assessed by logistic regression (Fig. 1), confirming the independent prognostic role of baseline FRAIL score in patients with IE [OR 1.5 (1.2-2.3) and 2.0 (1.5-2.6), respectively, for every additional scale point]. Conclusions frail patients with IE were older, more prone to enterococcal infections and in-hospital complications and had greater comorbidity burden. Both PET/CT and cardiac surgery were less performed in this group, which was characterized by a higher predicted surgical risk, as well as a worse short and mid-term prognosis.

Can variants of genes associated with familial heart block predict conduction disease in the general population? A UK Biobank study.

Abstract Background Progressive familial heart block is a genetic disease that can present with worsening cardiac conduction disease (CCD) and risk of life-threatening bradycardia. The prevalence, penetrance, and expressivity of known rare pathogenic/likely pathogenic variants (P/LP) in the general population is unclear. In addition, the role of common genetic variation in this phenotypic expression is unknown. Understanding this is essential for patient management in clinic. Purpose 1). To investigate the prevalence of variants linked with early-onset CCD and phenotypic expression in a large biobank. 2). To investigate whether a PR interval polygenic risk score (PRS) improves risk prediction. Methods Early-onset conduction disease P/LP or variants of uncertain significance (VUS) were identified from ClinVar, genetic testing reports at a teaching hospital (6 variants), and the literature, mapping to 22 genes. From the full UK Biobank prospective cohort, 469,511 participants passed genetic quality control and were assigned to P/LP, VUS, or genotype negative (G-) groups, using whole exome sequencing analysed with bcftools. A PR-PRS was constructed using weights from a published meta-analysis excluding UKB data. The primary outcome was CCD (atrioventricular (AV) block, bundle branch block, pacemaker or ICD implantation) and secondary outcomes were high-grade AV block or pacemaker insertion, compared with lifetime risk Cox proportional hazards controlled for sex and age as a timescale. Results 55% of participants were female, 95% had European ancestry, and average age at censor was 71 years. There were 25 P/LP carriers, and 8,862 with a VUS, in 6 genes (MYH7, SCN5A, TNNI3K, TRPM4, TTN, and LMNA). Major demographic factors were the same between groups. CCD was significantly more prevalent in P/LP individuals (28% vs 5.8% in VUS vs 5.5% in G-; p<0.001) with a hazard ratio of HR 6.47 [95% CI=3.09-13.6] vs G-. This was driven by AV block and pacemaker implantation (HR 23.2 [95% CI=8.69-61.8] and 13.4 [95% CI=6.01-29.8], respectively). Results were similar in an unrelated subset and controlling for ischaemic heart disease and heart failure. The 7 P/LP individuals with conduction disease were mostly linked to a single LMNA variant (4 out of 6 carriers with penetrant disease). In the full cohort, the PR-PRS was predictive of CCD (HR=1.07 [95% CI=1.06-1.08]), AV block (HR=1.09 [95% CI=1.06-1.13]), and pacemaker implantation (HR=1.04 [95% CI=1.02-1.06]). When combined with P/LP status, both PR-PRS (HR=1.07 [95% CI=1.06-1.08]) and P/LP (HR=6.42 [95% CI=3.06-13.5]) were independent predictors of CCD. Conclusion(s) Rare variant carrier status predicts a 6.5-fold increased lifetime risk of CCD, a 23-fold increased risk of AV block and 13-fold risk for pacemaker requirement. However, phenotypic expression for some variants is highly variable. A PR-PRS captures risk independent of P/LP variants and warrants further investigation with updated PRS construction methods.

Sex differences in clinical characteristics, phenotypes, management, and long-term outcomes of myocardial injury: an international cohort study

Abstract Background Several studies have demonstrated sex differences in patients presenting to the emergency department (ED) with myocardial infarction, heart failure or syncope. Whether sex-specific differences in chest pain patients with myocardial injury exist is unknown. Purpose To determine whether sex-specific differences in the clinical characteristics, phenotypes, management, and long-term outcomes of patients with myocardial injury exist. Methods Patients presenting to the ED with chest pain suggestive of MI were consecutively enrolled into a prospective multicenter international diagnostic study. Final diagnoses were centrally adjudicated by two independent cardiologists, applying the fourth universal definition of myocardial infarction, using all available medical records, including serial hs-cTn and cardiac imaging. Follow-ups were performed at 3 months, 1-, 2- and 5-years. The primary outcome was 5-year all-cause mortality. Secondary outcomes included 5-year cardiovascular mortality and non-cardiovascular mortality. Multivariable flexible parametric (Royston-Parmar) models assuming proportional hazards were fitted. Models were adjusted for age, history of coronary artery disease, history of malignancy, diabetes, hypertension, smoking status, history of liver disease, and renal function. Results Among 8046 chest pain patients presenting to the ED, 1158 (14.4%) had myocardial injury, of which 358 (31%) were females and 800 (69%) males. Women were older (79 years, vs. 73 years), had fewer cardiovascular risk factors and comparable non-cardiovascular comorbidities except for lung disease which was more commonly found in men. Myocardial injury phenotypes varied between sexes (Figure). The most common phenotype in both sexes was heart failure, yet it was more common in men (37.2%) than in women (22.3%). The second most common phenotype in women was hypertension (15.4%) and arrhythmia (15.4 %), while in men was myocarditis (17.8 %), followed by arrhythmia (15.8%). Women underwent less invasive coronary angiography (19.8% vs 26.9%) or stress testing (12% vs 21.5%). In the angiographic findings, women presented more often with normal findings (30.4% vs. 19.6%) or mild CAD (20.3% vs. 11.2%) whereas men displayed more frequently 3-vessel disease (14.5% vs. 36.4%), Table. After adjusting for known confounders, women were associated with a lower 5-years risk for all-cause mortality (HR 0.69; 95%CI: 0.56–0.83) and cardiovascular mortality (HR 0.61; 95%CI: 0.46–0.79). No statistically significant difference in non-cardiovascular mortality risk was found (HR 0.79; 95%CI: 0.59-1.04). Conclusions Women presenting with chest pain to the ED and having myocardial injury were less likely than men to undergo coronary angiography or non-invasive cardiac imaging. Long-term risk for all-cause or cardiovascular mortality was lower for women compared to men.Myocardial Injury phenotypesPatient management

Performance evaluation of ChatGPT 4.0 on cardiovascular questions from the medical knowledge self-assessment program

Abstract Background Medical trainees are increasingly using online chat-based artificial intelligence (AI) platforms as supplementary resources for board exam preparation and clinical decision support. Prior studies have evaluated the performance of AI chatbots like ChatGPT on various general standardized tests such as the United States Medical Licensing Examination (USMLE), but little is known about their performance on subspecialty-focused exam questions, particularly related to clinical management and treatment. Objective This study aims to evaluate the performance of ChatGPT version 4.0 on the cardiovascular questions from the Medical Knowledge Self-Assessment Program (MKSAP) 19, a widely used resource for board exam preparation in the United States. Methods We submitted all cardiovascular questions from MKSAP 19 to ChatGPT 4.0, covering a broad range of cardiology topics in a multiple-choice format. Performance was gauged against both the official MKSAP answer key and average trainee scores obtained from the MKSAP website. Out of 129 questions, 4 were invalidated due to post-publication data, and 18 were excluded due to reliance on visual aids, leaving 107 questions for analysis. Results ChatGPT 4.0 correctly answered 93 out of 107 questions, reflecting an 87% accuracy rate, compared to a 60% accuracy rate averaged among all human users for the same questions (p<0.0001). ChatGPT accuracy rates for each question category (e.g., heart failure, electrophysiology, etc.) are provided in the figure. On the 14 questions that ChatGPT answered incorrectly, human users averaged a 47% accuracy rate. All 14 incorrectly answered questions were related to clinical management and treatment (as opposed to diagnosis or epidemiology), and the majority (10/14) involved choosing treatment medications or choosing between medications versus interventions. Conclusion ChatGPT 4.0 surpassed the typical 70% accuracy threshold required for passing the internal medicine board certification but performed less well in answering questions about clinical management and treatment. This performance suggests that ChatGPT 4.0 could be an effective adjunct tool for cardiology education, but raises some concerns about its use in clinical decision support for trainees.

Development of phage-containing hydrogel for treating Enterococcus faecalis-infected wounds.

Chronic wound infections caused by Enterococcus faecalis pose formidable challenges in clinical management, exacerbated by the emergence of vancomycin-resistant strains. Phage therapy offers a targeted approach but encounters delivery hurdles. Due to their biocompatibility and controlled release properties, hydrogels hold promise as carriers. This study aimed to fabricate phage-containing hydrogels using sodium alginate (SA), carboxymethyl cellulose (CMC), and hyaluronic acid (HA) to treat E. faecalis-infected wounds. We assessed the efficacy of these hydrogels both in vitro and in vivo. The hydrogel was prepared using SA-CMC-HA polymers. Phage SAM-E.f 12 was incorporated into the SA-CMC-HA hydrogel. The hydrogel's swelling index was measured after 24 h, and degradation was assessed over seven days. Surface morphology and composition were analyzed using Scanning Electron Microscopy (SEM) and Fourier-transform infrared spectroscopy (FTIR). Antibacterial activity was tested via optical density (OD) and disk diffusion assays. Phage release and stability were evaluated over a month. In vivo efficacy was tested in mice through wound healing and bacterial count assays, with histopathological analysis. Hydrogels exhibited a swelling index of 0.43, a water absorption rate of %30, and 23% degradation over seven days. FTIR confirmed successful polymer incorporation. In vitro studies demonstrated that phage-containing hydrogels significantly inhibited bacterial growth, with an OD of 0.3 compared to 1.1 for the controls. Hydrogels remained stable for four weeks. In vivo, phage-containing hydrogels reduced bacterial load and enhanced wound healing, as shown by improved epithelialization and tissue restoration. Phage-containing hydrogels effectively treat wounds infected with E. faecalis-infected wounds, promoting wound healing through controlled phage release. These hydrogels can improve clinical outcomes in the treatment of infected wounds.

Real world economic evaluation of CT-FFR in patients with suspected coronary artery disease

Abstract Background Incorporation of CT-derived fractional flow reserve (CT-FFR) enhances the precision of Coronary CT Angiography (CCTA) to detect hemodynamically significant coronary artery disease (CAD). However, the financial consequences remain unclear. Purpose Our objective is to assess the economic implications of CT-FFR in the Dutch Healthcare system. Methods This retrospective, single-center cost effectiveness analysis includes patient data of a previously published study assessing the impact of routine CT-FFR availability on clinical management. We collected medical resource use for both diagnostic and therapeutic cardiovascular care with a follow-up duration of 1 year. Costs of CT-FFR analysis were set at €1000, its current price for Dutch hospitals. Median total costs at were compared using the Wilcoxon rank sum test, including a sensitivity analysis in which cost estimations (without registered maximum tariffs) were increased or decreased with 10%. Results A total of 360 patients, classified as having low to intermediate risk of CAD, were enrolled in the study – 224 in the CCTA group and 136 in the CT-FFR group. In addition to undergoing more (invasive) diagnostic testing and revascularization procedures over the studied period, patients in the CCTA-group had more outpatient clinic consultations (p<0.001), presented more frequently to the emergency department (p=0.035) and spend more nights in the hospital (p=0.11). Median costs were €3.347 (IQR €1.066 – €4.862) in the CCTA-group and €1.436 (IQR €1.362 - €3.943) in the CT-FFR group (p=0.091). Increasing cost estimation with 10% revealed a median of €3.431 in the CCTA-group versus €1.479 in the CT-FFR group (p=0.078), decreasing with 10% showed median costs of €3.263 in the CCTA-group and €1.392 in the CT-FFR group (p=0.118). In our sample, CT-FFR guided care would have been significantly cheaper than CCTA-guided care at or below a market price of €770. Conclusion Despite the significant reduction in additional diagnostic testing and hospital visits in the CT-FFR group, CT-FFR guided care was not cheaper than CCTA-guided care at its current market price of €1.000. Economic cost-effectiveness would have occurred from a price of €770 per analysis. The large difference between medians suggests that the lack of significance might partially be attributed to insufficient power in this relatively small sample size. Additionally, this study did not account for costs associated with loss of productivity and quality of life. However, less additional diagnostic testing, less revascularization procedures and less hospital consultations and admissions leads to reduction in hospital resource consumption and patient burden, which is an important advantage of CT-FFR as the number of referred patients increases yearly.